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Insurance Intake Form
Please complete all required fields to help us process your application.
First Name:
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Last Name:
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Date of Birth:
*
E-mail address:
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Your Cell Phone Number
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Health Plan Name (i.e., United Healthcare, Blue Cross)
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Insurance ID#
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Tel # on back of Insurance Card for Providers or Eligibility
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SECONDARY Insurance Company
SECONDARY Insurance ID#
Your Mailing Address (Cannot process without all these details: Street, City, State, Zip)
*
Please include your full street address, city, state, and zip.
If you've been given an Auth, add the long Authorization #
If you've been given an Auth, add the 5-digit CPT Code (i.e. 90791 or 90792)
Medical Group (i.e. PIH Health/Applecare MG)
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YES/NO: I know that I must also fill the other form below called "Part 2 - Online Intake" in order for my application to be complete.
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Yes
No
Submit
*Required